Claim Benefit Specialist Ops- Remote

CVS Pharmacy; Tallahassee (FL); Remote; Full time

Job summary

An established industry player is seeking dedicated individuals to join their team in transforming healthcare. This role focuses on the review and adjudication of claims, ensuring compliance with guidelines and standards. Candidates will utilize various computer applications and systems to manage claims efficiently. With a commitment to fostering a supportive workplace, this organization offers competitive pay and comprehensive benefits designed to enhance the well-being of employees. If you're passionate about making a difference in healthcare and thrive in a dynamic environment, this opportunity is perfect for you.

Benefits

Affordable medical plan options

401(k) plan with company matching

Employee stock purchase plan

Wellness screenings

Tobacco cessation programs

Weight management programs

Confidential counseling

Financial coaching

Tuition assistance

Flexible work schedules

Qualifications

• 1 year experience in a production environment required.
• Ability to work with multiple computer applications simultaneously.

Responsibilities

• Reviews and adjudicates routine claims on HRP system.
• Analyzes and approves claims that cannot be auto adjudicated.

Skills

Claims Processing

Computer Navigation

Research Skills

Attention to Detail

Education

High School or GED equivalent

Tools

Microsoft Outlook

Microsoft Office

Job description

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Responsibilities

Reviews and adjudicates routine claims on HRP system in accordance with claim processing guidelines. Claims adjudication results should meet/exceed production and quality standards in line with CMS and Aetna compliance and business requirements.

1. Analyzes and approves routine claims that cannot be auto adjudicated.
2. Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
3. Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
4. May facilitate training when considered topic subject matter expert.
5. In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).
6. Utilizes all applicable system functions available ensuring accurate and timely claim processing.

Required Qualifications

• 1 year Experience in a production environment
• No PTO within the first 90 days
• On-Video Training Required
• Ability to research and work within several computer applications simultaneously
• Microsoft Outlook

Preferred Qualifications

• 1 year Claims processing experience
• Computer Navigation Proficiency
• Production & Quality background
• Microsoft Office tools
• Detailed and quality oriented

Education

High School or GED equivalent

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$17.00 - $31.30

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/16/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.